Deciphering the enigma of female urethral strictures: A systematic review and meta‐analysis of management modalities (original) (raw)
Related papers
Female urethral stricture: techniques for reconstruction
Plastic and Aesthetic Research, 2022
Female urethral stricture (FUS) is a rare condition. It was not studied robustly for many years, but interest has grown recently in the reconstructive urology community, leading to an increase in publications. In this review, we gather the latest data regarding FUS and its different therapeutic options. Studies are summarized, split by technique. We also review the recently published European Guidelines. In addition, we share our preferred surgical technique and our views on future options. Diagnosing FUS can often be challenging and requires a high index of clinical suspicion. Its vague clinical symptoms and empiric initial treatments combine to make FUS an underdiagnosed condition. The lack of consensus on how to define FUS also compounds the problem. Appropriate diagnosis requires thorough investigation, and ancillary studies such as video urodynamics, cystoscopy, and voiding cystourethrogram may be useful. Treatment options range from conservative management to definitive procedures, although studies have shown that conservative measures such as urethral dilation have a low success rate overall. Within definitive management, augmented urethroplasty - using either flaps or grafts, has proven to be the gold standard. Both have shown excellent results over time; however, there is insufficient data available to recommend one over the other. Contemporary data has an overall poor level of evidence. Although challenging due to the rarity of the problem, a proper randomized controlled clinical trial comparing the principal surgical options and their outcomes would be beneficial and would allow for more informed decision making when considering options for women with urethral stricture.
Management of Urethral Stricture in Women
The Journal of Urology, 2012
We describe the diagnosis and treatment of urethral strictures in women. Materials and Methods: We retrospectively identified female urethral strictures from 1998 to 2010. Study inclusion criteria were 1) clinical diagnosis of stricture, 2) stricture seen on cystoscopy, 3) urethral obstruction on videourodynamics according to the Blaivas-Groutz nomogram and/or 4) urethral caliber less than 17Fr. Postoperative recurrence was defined by the preoperative criteria. Results: We identified 17 women with a mean age of 62 years (range 32 to 91) with stricture. Stricture was idiopathic in 8 patients, iatrogenic in 6, traumatic in 2 and associated with a urethral diverticulum in 1. Videourodynamics could not be done in 3 women due to complete obliteration of the urethra. Ten of 14 patients satisfied videourodynamic criteria for obstruction and 4 had impaired detrusor contractility. Nine women underwent vaginal flap urethroplasty, including 5 who also had a pubovaginal sling and 1 who had a Martius flap. One patient received a buccal mucosal graft as primary treatment after initial dilation. There was no recurrence at a minimum 1-year followup but 2 strictures recurred 5½ and 6 years postoperatively, respectively. These 2 women received a buccal mucosal graft and were stricture free 12 to 15 months postoperatively. Of 17 patients initially treated with urethral dilation recurrence developed in 16, requiring repeat dilations until urethroplasty was performed. Conclusions: In select women vaginal flap urethroplasty and buccal mucosal graft have high success rates, including 100% at 1 year and 78% at 5 years. Urethral dilation has a 6% success rate. Long-term followup is mandatory. Treatment should be individualized.
Pakistan Journal of Medical and Health Sciences
Background: Normally female urethral stricture (FUS) is uncommon and underdiagnosed condition. It is raising a diagnostic challenge for the physicians. It is the one of the rarely known urological entity. Urethral dilatation is the traditionally used treatment for urethral stricture (FUS). The female urethroplasty have shown the promising outcomes. Objective: The objective of the study was to compare the outcome of the dorsal onlay urethoplasty FU obtained by using buccal mucosal graft and vaginal wall graft. The FU is more effective treatment for female urethral stricture (FUS) as compared to the repeated dilatation. Study design: It is a retrospective study with the statistical approach, conducted at Urology Department, Pakistan Institute of Medical Sciences Islamabad from June 2021 to November 2021. Material and Methods: The women who underwent the dorsal onlay urethropasty at the urology department of the hospital were included in the study. The outcomes of BMG and VWG were comp...
Female Urethroplasty: Outcomes of Different Techniques in a Single Center
Journal of Clinical Medicine, 2021
Introduction: Female urethral strictures and injuries are relatively uncommon compared to males. A wide range of possible causes and treatment modalities have been described. Lately female urethral reconstruction is gaining attention and is fortunately no longer a neglected topic within the reconstructive urology. As such, we aimed to describe our surgical techniques and outcomes for female urethroplasty from a tertiary center. Materials and Methods: Records of female patients who underwent a urethroplasty between July 2018 and May 2021 in our tertiary referral center were reviewed. Patients were subdivided in two groups: patients who suffered from a urethral injury and received an early repair urethroplasty, and patients with a true urethral stricture who received a delayed urethroplasty. Preprocedural, surgical and postoperative data were collected and analyzed with descriptive statistics. Results: A total of five patients in group 1 and nine patients in group 2 were included. Eti...
Ventral Inlay Labia Minora Graft Urethroplasty for the Management of Female Urethral Strictures
Urology, 2014
OBJECTIVE To evaluate the functional outcomes of ventral inlay labia minora graft urethroplasty (VILGU) for the management of female urethral strictures. METHODS Data of 7 consecutive women treated with VILGU between 2011 and 2013 were reviewed. Two patients had cystostomy tubes at repair, and 5 had undergone previous urethral dilations and urethrotomies. Clinical evaluation included assessment of the effect of voiding symptoms with American Urological Association (AUA) symptom score, uroflowmetry, voiding cystourethrography, and intraoperative urethrocystoscopy using a 6.5F pediatric ureterorenoscope. Preoperative AUA symptom score and peak urinary flow rate were compared with postoperative values. Cure was defined as the absence of any restenosis requiring additional intervention with subjective patient satisfaction at the last follow-up. RESULTS Mean stricture length was 1.5 cm (range, 1-2.5), and mean operative time was 95 minutes (range, 70-110). With a mean follow-up of 18.2 months (range, 3-30), cure was achieved in 6 (86%) women. At the last follow-up, mean maximum urine flow (mL/s) increased from 3.9 AE 3.1 preoperatively to 22.7 AE 8.3 postoperatively (P <.001), and mean AUA symptom score decreased from 25.3 AE 5.2 preoperatively to 6.9 AE 3.7 postoperatively (P ¼ .001). No fistulae developed after surgery. "De-novo" stress urinary incontinence was not evident in any case. CONCLUSION VILGU effectively provides better urinary flow and significantly improves patient satisfaction in patients with female urethral stricture disease. UROLOGY 83: 460e464, 2014.
Urethroplasty : a review of indications , techniques and outcomes
rethral stricture is the most common cause of lower urinary tract obstruction in men aged between 20 and 40, carrying an estimated overall prevalence of 0.5% in the UK [1] and results in around 17,000 hospital admissions annually [2]. Endoscopic management, by urethral dilatation or optical urethrotomy, has traditionally been the mainstay of surgical treatment, however high recurrence and poor long-term success rates have led to the development of novel techniques. Reconstructive surgery, namely urethroplasty, is an increasingly common option in the surgical management of both primary and recurrent urethral stricture, and produces encouraging long-term results. This article will discuss the basis for urethroplasty, the techniques involved and the current evidence-base behind the trend towards this treatment, particularly in the context of stricture disease.
Urethroplasty; Wide Range of Therapeutic Indications and Surgical Techniques
Urethroplasty means plastic surgery of the urethra. Herein we are going to describe urethroplasty in terms of; diagnosis, indications, surgical techniques and definition of failure or success. A lot of issues related to urethroplasty remain to be defined, therefore we will clarify the debatable issues and highlight the last advances on urethroplasty. There are two main causes which mandate ur ethroplasty; the first is the congenital anomalies with hypospadias being the most common, and the acquired anomalies with urethral stricture being the most common of them. Hypospadias is found commonly in newborn boys and it seen in approximately 8.2 per 1000 births. The goal of hypospadias reconstruction are to bring the meatus close to glans to allow the child to void standing, removing the chordee to allow for normal sexual intercourse and giving the phallus appearance of a normally circumcised penis wh en observed from distance. There are more than 200 named surgical procedure to correct hypospadias. Now a days tubularized incised plate (TIP) urethroplasty described by Snodgrass in 1994 is the most common procedure used for repair of hypospadias. The advantages of this technique include its simplicity, high success rate, low rate of complication and excellent cosmetic results. A lot of modifications were introduced on the TIP urethroplasty aiming to improve the success rate and to decrease fistula formation. We were from the firsts who published such modification regarding the use of double- layer dartos flap covering for urethra instead of the classic way of utilizing dorsal dartos flap (button hole maneuver). The second cause of urethroplasty is the acquired anomalies. Strictures of urethra is of much clinical important than hypospadias, because it bothers the patients more, unfortunately the results of surgery is not promising as that of hypospadias. The term “urethral stricture” refer to anterior urethral disease or scaring pr ocess involving the spongy erectile tissue of the corpus spongiosum (spongiofibrosis). According to World Health Organization posterior urethral stricture are not included in the common definition of urethral stricture and the term stricture is limited to the anterior urethra. Urethral disruption injuries typically occur in conjunction with multisystem trauma from vehicular accident, falls, or industrial accident. Because the posterior urethra is fixe d at both the urogenital diaphragm and the puboprostatic ligaments, the bulbomembranous junction is more vulnerable to injury during pelvic fractures. When the fracture occur the two separa ted ends fill with scar tissue, resulting in a complete lack of urethral continuity. The location of urethral strictures was classified as penile(including navicularis fossa) , bulbar or posterior (excluding bladder neck contractures).While posterior urethral strictures were commonly caused by traumatic disruption distinctly different from etiology compared to that of anterior strictures disease, recurrence was monitored with the same procedure used for surveillance of anterior urethral reconstruction. The Urethral disruption is heralded by the tria d of blood at the meatus, inability to urinate, and palpably full bladder. When blood at the urethral meatus is discovered, an immediate retrograde urethrogram should be performed to rule out urethral injury.When urethral stricture is diagnosed immediate suprapubic tube placement remains the standard of care. While the diagnosis of hypospadias needs no radiologic tests, diagnosis of urethral stricture is a matter of discussion. The most common primary diagnostic tests are uroflowmetry (56%), urethrography (51%) and cystourethro scopy (21%). Definition of recurrence of stricture or failure of surgery is also a questionable issue. In 75% of papers regarding urethroplasty, recurrence was defined as the n eed for additional surgical procedure and in 52% as the need for additional urethral dilation. The treatment of urethral strictures is divide d in two groups; endoscopic and open surgery. The endoscopic treatment such as direct-visio n internal urethrotomy are the best reserved for selected short urethral stricture. However wh en the defects are 1 cm or longer or when a significant corpus spongiofibrosis is present , endoscopic procedure such as cutting through the pelvic scare”cut-to-light” are ineffective. Despite the popularity of this procedure the failure rate after initial urethrotomy is reported to be at least 50%. The failure rate after the second urethrotomy is considered much higher and can be as high as 100%. Therefore there has been continuing discussion about the most appropriate use of urethrotomy, dilation, stenting, and intermittent self dilation. Question have also su rfaced about the best technique for urethrotomy. There is no compelling evidence in the literature that any particular form of urethrotomy is more effective than anothe r, whether using a cold knife or laser. The second treatment option is open surgical reconstruction. There are two kinds of open surgical techniques used for urethroplasty; anastomotic urethroplasty and substitution urethroplasty. Anastomotic urethroplasty involves excision of the strictures and primary anastomosis of urethral ends. Open posterior urethroplasty through a perineal anastomotic approach is the treatment of choice for the most urethral distraction injuries because it definitely cure the patient without the need for multiple procedure. Care must be taken to carefully and meticulously excise all fibrotic tissue from the proximal urethra margin until at least a 28 french bougie passes without resistance. Free tension end to end anastomosis is the procedure of choice when the scar is 1.5-2 cm long and this is highly successful procedure in more than 95% of cases. Urethroplasty remains the gold standard for the management of urethral stricture offering the lowest rate of stricture recurrence and in some circumstance the most cost-effective compared to repeat dilation or endoscopic incision. The limiting factors with anastomotic urethroplasty is the strictures length, in particular the length of component distal to bulbopenile ju nction. Anastomatic procedure in the bulbar urethra resulted in a significant impairment of erectile function initially which improved in the majority of cases with a low of long term erectile dysfunction. The second kind of urethroplasty is substitution urethroplasty. Recent advances in tissue graft sources and the introduction of tissue sealants improve surgical outcomes and minimize patients morbidity by decreasing the number of surgical procedures and the potential disfigurement related to graft site morbidity. Substitution urethroplasty can be performed as a one-stage procedure via an augmented anastomotic procedure, patch substitution (onlay procedure) or a circumfe rential patch, or two-stage procedure which involves the formation of a roof strip followed be second stage tubularization. It has been shown that the efficacy of both grafts and fl aps was identical , but there was a much higher morbidity with penile skin flaps which were also more complex with higher morbidity. The graft which has been used included scrotal skin, oral mucosa, extrag enital skin, bladder mucosa, and colonic mucosa. The success rate at average follow-up of 53 months was reported to be 60% for augmented anastomo tic repair and 80% for onlay procedure. In conclusion urethroplasty especially in patients with urethral stricture required the urologist to be aware of the techniques which offer the patient the best success. Therefore different considerations have to be taken in to account like length , location, anatomy and etiology of stricture. In comparison to reconstruction of urethral stricture, urethroplasty done due to hypospadias seems to be less complicated with high success rate at long term follow-up.
Dorsal Graft Urethroplasty for Female Urethral Stricture
The Journal of Urology, 2006
Purpose: Urethral strictures in females are uncommon, and treatment options and outcome are not well-defined with scanty reports. We describe a new method of urethroplasty for the repair of female urethral stricture. Materials and Methods: Three 60-year-old females, each with a history of recurrent urinary tract infections and obstructive voiding symptoms due to urethral stricture, underwent urethroplasty with a dorsal vaginal or buccal mucosal graft. The dorsal aspect of the distal urethra was dissected from the surrounding tissue through a suprameatal incision and the urethral wall was incised through the stricture at the 12 o'clock position. A 1.5 cm wide free graft was harvested from the vaginal wall or buccal mucosa in 1 case, and the mucosal surface was placed upon the urethral lumen and sutured with a running 5-zero polyglactin suture to the open urethra. Indwelling 18Fr urethral and 16Fr suprapubic catheters were left in place for 2 and 3 weeks, respectively. Results: No additional treatment was required during the 1, 8 and 27 months of followup. All patients had normal micturition following catheter removal. Conclusions: Dorsal graft urethroplasty is feasible and effective for the correction of persistent female urethral stricture.
Ventral-onlay buccal mucosa graft substitution urethroplasty for urethral stricture in women
BJU international, 2017
To present our outcomes of ventral-onlay buccal mucosa graft (BMG) substitution urethroplasty in treating female urethral stricture (FUS). We conducted a review of a prospectively collected database of 22 consecutive women (median [range] age 50 [34-72] years) with urethral stricture who underwent ventral onlay BMG substitution urethroplasty after June 2012 and who had a minimum follow-up of 6 months (median 21.5, range 6-51 months). Data were analysed for stricture recurrence, change in median maximum urinary flow rate (Qmax ) and median post-void residual urine volume (PVR). Statistical analysis was performed using the Wilcoxon signed rank test, Student's t-test and the Mann-Whitney U-test. Freedom from stricture recurrence was achieved in 21/22 (95.5%) women. The median (range) Qmax significantly improved, increasing from 7 (3.5-11) to 18 (5-37) mL/s (P <0.05). The median (range) PVR was significantly reduced from 100 (0-300) to 15 (0-150) mL (P < 0.05). Short- and long...